Considering rural living and working characteristics

30 Global evidence on inequities in rural health protection

4.2.1. Considering rural living and working characteristics

About 70 per cent of the developing world’s 1.4 billion extremely poor people are currently living in rural areas IFAD, 2011. In other words, high poverty rates are linked to high percentages of people living in rural areas compared to urban areas. Most rural dwellers in developing countries depend on agriculture for their livelihood and subsistence agriculture is common. However, the rural population also participate in rural labour markets that are often characterized by informality of work, unemployment, and significant challenges as regards decent work. For example, among the rural poor in India casual wage labour is the largest single occupational group ILO, 2008. This form of labour is unstable, as wages are paid on a task or piecemeal basis and as a result workers are highly vulnerable both to risks associated with agriculture e.g. natural hazards such as droughts and to seasonal variations in employment opportunities. The situation is aggravated by the fact that state-run social protection coverage often focuses only on the organized sectors of public and industrial employment, leaving the vast majority of rural populations that operate in the informal economy without any means of income support ILO, 2011a. The wages of employed rural populations are frequently low and the often physically demanding work offers few opportunities to invest in developing skills and building assets to generate higher incomes. Persistent poverty and limited employment opportunities for decent jo bs are also major “push factors” that are responsible for the migration of formerly rural dwellers into urban slums ILO, 2008. Self-employed small-scale farmers in developing countries also face obstacles in income generation. Local value chains have high transaction costs and are hampered by inadequate infrastructure, long distances and restricted access to financial and business services. As a result, it is difficult for these producers to become suppliers to larger firms, compete in global value chains and enter higher value markets. Due to their size and lack of organization in cooperatives or other producer organizations, small enterprises in rural areas also do not have enough bargaining power to improve their situation ILO, 2011a. In addition to economic exclusion and lack of economic opportunities, rural populations largely remain excluded from participatory processes within the overall society they live in. Where political representation is absent, legislation and related resource allocation patterns tend to favour urban areas, particularly for public services including education and health. This “urban bias” is fuelled by better-off interest groups in cities that are able to lobby the government to spend money on the services they want, while the poor in rural areas suffer from underinvestment. Social exclusion and the lack of access to services are most severe for those who are most at risk of poverty. Within rural populations, these are particularly women, the elderly, minority groups and migrants. These characteristics require specific efforts to include rural populations in meaningful health protection that results in effective access to health care when needed. Affordability, availability and financial protection of legally anchored health protection need to be at the centre of successful policies towards universal health coverage. Global evidence on inequities in rural health protection 31

4.2.2. Moving from charity to rights